Provider Demographics
NPI:1205903986
Name:CONNELLY, ROGER JOHN (OD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:JOHN
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:NH
Mailing Address - Zip Code:03079-3379
Mailing Address - Country:US
Mailing Address - Phone:603-893-5288
Mailing Address - Fax:603-893-4663
Practice Address - Street 1:167 S BROADWAY
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:NH
Practice Address - Zip Code:03079-3379
Practice Address - Country:US
Practice Address - Phone:603-893-5288
Practice Address - Fax:603-893-4663
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4560152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist